Provider Demographics
NPI:1063639474
Name:CARLSON, MATTHEW TODD (LPC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TODD
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 W WINNEMAC AVE
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2816
Mailing Address - Country:US
Mailing Address - Phone:651-235-3351
Mailing Address - Fax:
Practice Address - Street 1:3040 N WILTON AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-4424
Practice Address - Country:US
Practice Address - Phone:773-296-7623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor